The mission of the CCG SAR program is to save and protect lives in the marine environment, and one of the CCG's objectives is to maintain the highest professional standards. CCG management's goal is to ensure that the SAR program operates at maximum efficiency by adjusting SAR coverage requirements as needs change, and by deploying specialized primary SAR units as required. SAR program management cooperates with other program managers in the deployment of multi-tasked resources in an effort to further enhance response capabilities. This analysis focuses on the conditions of the occurrence, as well as the decisions and actions made by CCG management and the crew of the craft that resulted in this crew responding to a SAR mission request in the Siyay.Analysis The mission of the CCG SAR program is to save and protect lives in the marine environment, and one of the CCG's objectives is to maintain the highest professional standards. CCG management's goal is to ensure that the SAR program operates at maximum efficiency by adjusting SAR coverage requirements as needs change, and by deploying specialized primary SAR units as required. SAR program management cooperates with other program managers in the deployment of multi-tasked resources in an effort to further enhance response capabilities. This analysis focuses on the conditions of the occurrence, as well as the decisions and actions made by CCG management and the crew of the craft that resulted in this crew responding to a SAR mission request in the Siyay. Acquisition Process Replacing the SRN-6 hovercrafts with the multi-mission AP1-88/400s was a strategic decision made to meet the SAR program goals. However, the acquisition process did not fully address mission requirements and expected operational conditions of the primary SAR role at Sea Island Base, namely night-time SAR. The CCG did not consider or require ergonomic principles in the design of the craft, which resulted in significant design limitations. A fully ergonomically designed ship requires systematic integration of human factors into system design processes. Such an approach requires a specific plan for involving representative personnel responsible for operation and maintenance of the system at the design, development, testing, and commissioning stages working with ergonomic specialists. This type of plan, a Human Engineering Program Plan, serves as a road map for ergonomic design efforts.3 Such a comprehensive plan contains the following elements (seeAppendixA for details): Management commitment to the ergonomic function. Systems and task analyses to identify and analyze functions to which ergonomic principles are to be applied. Ergonomic support of vendors and sub-contractors. Ship plan review for ergonomic consideration. Document and manual review for ergonomic consideration. Documentation of all ergonomic design principles incorporated into the ship's design. Ship check during construction to ensure ergonomic recommendations are appropriate. Test program to ensure systems were built to ergonomic standards. Ergonomic Design The ergonomic design issues identified with respect to SAR operations in the AP1-88/400 are of particular concern given the safety-critical nature of SAR tasks. A number of factors influence the degree of visibility required from the helm: task requirements; operating speed (e.g. faster speeds require greater visibility for a timely response); and location of the lookout (e.g. bridge wing lookouts decrease bridge visibility requirements). With regard to the AP1-88/400, the task requirements include being able to operate at high speeds and pulling alongside people or boats in the water and on potentially crowded shores, day or night, and in poor visibility. Visibility from the control cabin is therefore a critical factor. The illumination of water spray by the searchlights reportedly caused the pilot to lose visual reference to the shore. Water spray is particularly problematic when the vessel is operating at low speed. Given the existing control cabin configuration of the Siyay, operational procedures become an important method of compensating for the visibility limitations created by the design. These policies and procedures were not developed at the time of the occurrence. Training Program for the AP1-88/400 The differences in size, configuration, and handling characteristics between the SRN-6 and the AP1-88/400 are significant. Thus, the transition from the smaller to the larger craft requires a full training program, developed specifically for the unique operating environment of west coast SAR. A training program, whether it is initial training, familiarization training, or refresher training, should result in the trainee being able to perform the required tasks to a predetermined, measurable, and demonstrable level of competence. A formal training program did not exist at the CCG, nor were resources dedicated entirely to developing and implementing a training program for the introduction of the AP1-88/400 to Sea Island Base. Training developed for the operational environment of the Laurentian region was being adapted on a trial-and-error basis to address west coast SAR operations. Training design is a critical element of any training program as the training content must be appropriately structured and presented for optimum learning. While the training plan at Sea Island Base demonstrated some aspects of a training program, such as content, methods and strategies to achieve and assess the required level of competence were not in place. The risk of mishaps was increased by the CCG's decision to train personnel on the AP1-88/400 without the following: dedicated resources (e.g. human and time); a clearly developed philosophy of operation; well-documented and understood policies; and standard operating procedures. Staffing Levels CCG management recognized the shortage of qualified pilots trained to operate hovercraft. The decrease in the number of such experienced pilots at Sea Island Base during the three years prior to introducing the AP1-88/400 created difficulties in ensuring adequate human resources for maintaining service standards. Unique training requirements of individuals occupying a hovercraft position, as opposed to positions in the general fleet, eliminated the possibility of short-term relief and was compounded by training requirements on the new craft, where workload for staff increased considerably. While questions were raised about a crew member's fitness for duty seven months before the incident, management was aware of a work assessment, but chose not to undertake it partly as a result of staff workload and an inability to acquire short-term relief. Tasking craft captains to develop a AP1-88/400 training program and perform normal duties, coupled with chronic under-staffing of qualified pilots at Sea Island Base, represents a risk to the safe operation of the vessel. Policy on the Use of the AP1-88/400 The AP1-88/400 was being used for training and operational purposes by personnel at various stages of training. Given that there was no formal operational standard for determining when a crew was adequately trained to respond to an operational SAR tasking, the decision rested with the craft pilot, who could not provide an independent assessment of his/her own performance. The absence of a formal operational standard posed a higher risk to persons, equipment, and the environment during SAR operations, as the CCG could not ensure a minimum level of competence of AP1-88/400 crews. Procedures for the AP1-88/400 In most high-risk operations, procedures are support tools used to ensure safe and predictable operations. The nature of SAR operations requires relying on the knowledge and capabilities of the crews on scene; operations cannot be left up to the whim of the individual. Procedures can be designed to assist the crew by specifying sub-tasks and actions that ensure the primary task at hand will be carried out in an efficient, logical, and error-resistant manner. Standard operating procedures also promote coordination among crews and provide a common ground for crews unfamiliar with others' experience and technical capabilities. In this manner, standard operating procedures set the framework for good bridge resource management; determining individual roles enhances collective knowledge. The SRN-6 searchlight was designed to be used by the pilot. In contrast, the design of the AP1-88/400 searchlight calls for operation by someone other than the pilot. Standard procedures for operating searchlights had not been implemented, and the craft captain of the Siyaywas attempting to operate the starboard searchlight and pilot the craft in demanding conditions. The craft captain reduced speed and lift when he lost visual reference with the breakwater. However, these actions resulted in greater spray and increased the risk of striking an object underneath the craft. There were no procedures to guide the craft captain in deciding which actions would achieve the desired outcome. This situation illustrates that relying on skills and procedures developed on one type of craft might not be appropriate on another type of craft. While attempting to navigate through a gap in the Steveston Jetty, the Siyay contacted the breakwater because the craft captain lost visual reference to the sides of the gap. The pilot's forward visibility was obscured by the bow thrusters and the reflection of the searchlight on the water spray.Findings as to Causes and Contributing Factors While attempting to navigate through a gap in the Steveston Jetty, the Siyay contacted the breakwater because the craft captain lost visual reference to the sides of the gap. The pilot's forward visibility was obscured by the bow thrusters and the reflection of the searchlight on the water spray. Ergonomic principles were not fully integrated into the design and acquisition process of the AP1-88/400 craft, resulting in blind spots created by the bow thruster vents which also affected use of the searchlights; high night-time illumination levels in the fore section of the control cabin; and night-time window reflections, which compromise the safe operation of the vessel. Resources devoted to developing and implementing a training program for the AP1-88/400 were insufficient to ensure that trainees would be able to perform the required tasks to a predetermined, measurable, and demonstrable level of competence. The informal policy of allowing individual craft captains to decide on when and where to use the Siyayfor operational SAR missions, rather than a formal operational standard to determine when a particular crew was operationally ready, increased the risk that crews would not be at an adequate level of training for the mission at hand. The wind and current conditions at the gap in the breakwater required a high level of piloting skills. The crew on board the Siyaywas operating without the assistance of standard operating procedures designed specifically for that craft, resulting in poor bridge resource management (e.g. pilot operating a searchlight that required the use of both hands and should therefore have been delegated to another crew member), and inappropriate piloting decisions (e.g. the decision to enter the gap and the decision to reduce power and thrust upon losing visual reference of the gap entrance). Chronic staffing shortage for qualified hovercraft pilots at Sea Island Base compromised the 24-hours-a-day, 365-days-a-year operational readiness status at Sea Island Base. Procedures for requesting a fitness-to-work assessment of a staff member returning from stress leave were not pursued by management.Findings as to Risk Ergonomic principles were not fully integrated into the design and acquisition process of the AP1-88/400 craft, resulting in blind spots created by the bow thruster vents which also affected use of the searchlights; high night-time illumination levels in the fore section of the control cabin; and night-time window reflections, which compromise the safe operation of the vessel. Resources devoted to developing and implementing a training program for the AP1-88/400 were insufficient to ensure that trainees would be able to perform the required tasks to a predetermined, measurable, and demonstrable level of competence. The informal policy of allowing individual craft captains to decide on when and where to use the Siyayfor operational SAR missions, rather than a formal operational standard to determine when a particular crew was operationally ready, increased the risk that crews would not be at an adequate level of training for the mission at hand. The wind and current conditions at the gap in the breakwater required a high level of piloting skills. The crew on board the Siyaywas operating without the assistance of standard operating procedures designed specifically for that craft, resulting in poor bridge resource management (e.g. pilot operating a searchlight that required the use of both hands and should therefore have been delegated to another crew member), and inappropriate piloting decisions (e.g. the decision to enter the gap and the decision to reduce power and thrust upon losing visual reference of the gap entrance). Chronic staffing shortage for qualified hovercraft pilots at Sea Island Base compromised the 24-hours-a-day, 365-days-a-year operational readiness status at Sea Island Base. Procedures for requesting a fitness-to-work assessment of a staff member returning from stress leave were not pursued by management. The following actions have been taken since the occurrence: control cabin windows have been reconfigured to reduce glare; searchlight controls have been relocated; bow thruster vents and the forward ramp have been painted black to reduce glare; bow thruster controls have been relocated; an additional searchlight has been installed on the bow to account for blind spots caused by thruster vents and to reduce glare; the spray reduction skirt has been modified to enhance effectiveness; the Service Entry Plan for training has been formalized and is strictly adhered to; increased staffing has resulted in a sufficient complement of trained pilots and first officers to operate the Siyay; and the duty pilot will decide which hovercraft should be used for particular SAR missions.Safety Action The following actions have been taken since the occurrence: control cabin windows have been reconfigured to reduce glare; searchlight controls have been relocated; bow thruster vents and the forward ramp have been painted black to reduce glare; bow thruster controls have been relocated; an additional searchlight has been installed on the bow to account for blind spots caused by thruster vents and to reduce glare; the spray reduction skirt has been modified to enhance effectiveness; the Service Entry Plan for training has been formalized and is strictly adhered to; increased staffing has resulted in a sufficient complement of trained pilots and first officers to operate the Siyay; and the duty pilot will decide which hovercraft should be used for particular SAR missions.